Age-related changes in chronic illness or a life threatening illness can bring overwhelming challenges – difficult medical decisions, changing emotional and physical needs, fear, and anxiety. The diagnosis, particularly when it is unexpected, often puts a patient and family members at a loss.

There is a place for them to turn. The Franciscan palliative care outreach program helps people live the end of their lives as fully as possible. By integrating palliative care (pain and symptom management) with education, practical support, and links to a broad range of community and health care resources, we make sure the needs and desires of patients and their loved ones are heard, supported and met.

The goal of our program is to help patients with age-related changes or a life-threatening illness make informed choices with dignity, true understanding of all their medical options and the knowledge of what they can expect as their illness progresses.

Our program is based out of community medical clinics. This means we connect with recently diagnosed patients whose illnesses have not yet reached a point of crisis. By getting to know our patients at this point in their lives, we have time to help them make thoughtful, informed choices that reflect their wishes and values.

How our program works
Each of our patients faces unique circumstances, and we adapt the program to offer the best possible outcome in each case. Patients come to us via different paths, but typically a primary care provider is the first to put us in touch with a patient who may benefit from our program.

• Once we receive an initial referral, a nurse case manager contacts the patient to discuss the services we offer. The nurse serves as a reliable point of contact and advocate for the patient’s medical needs and access to care.
  
  
• When requested, a hospital-trained, certified chaplain will contact patients and their families for home visits and/or phone calls to foster quality of life, personal healing and spiritual renewal, as well as to discuss advance directive decision making.
  
  
• If desired, a volunteer is assigned to telephone the patient and family, making contact at least once a month. Our volunteers are specially trained to listen for pain or symptom management issues and remain in close contact with the nurse case manager.
  
  
• Upon request, an advanced care planning session, or family conference, is scheduled to bring the patient, family members, primary care provider, nurse case manager and chaplain together to discuss the future. The patient can use this time to talk about preferences for treatment and wishes. This session allows time to identity and respond to the patient’s needs for physical, emotional, social and spiritual care.
  

Hospice referrals
One important objective of our program is to bridge the gap between the time a person is diagnosed with a life-threatening illness and the time they become eligible for hospice services. The palliative care outreach team will talk to the patient and family members about the philosophy of hospice and the hospice Medicare benefit, and will help make a referral to a community hospice program when the time is appropriate.